Healthcare Provider Details

I. General information

NPI: 1841554508
Provider Name (Legal Business Name): COASTAL CARE TAMPA BAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 TAMIAMI TRL S STE 203
NOKOMIS FL
34275-3179
US

IV. Provider business mailing address

9040 TOWN CENTER PKWY 106A
LAKEWOOD RANCH FL
34202-4101
US

V. Phone/Fax

Practice location:
  • Phone: 941-306-1991
  • Fax:
Mailing address:
  • Phone: 941-306-1991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number30211572
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateFL

VIII. Authorized Official

Name: MISS VICTORIA PETTOGRASSO
Title or Position: PRESIDENT
Credential:
Phone: 941-306-1991